From the Guidelines
Patients on chronic proton pump inhibitor (PPI) therapy should have regular monitoring of magnesium, vitamin B12, iron studies, calcium, and creatinine to minimize the risk of morbidity and mortality associated with long-term PPI use. These labs should be checked at baseline before starting therapy and then periodically, typically annually, during long-term treatment 1. PPIs like omeprazole, esomeprazole, pantoprazole, and lansoprazole can reduce absorption of certain nutrients and affect kidney function over time. Specifically, PPIs decrease stomach acid, which impairs absorption of vitamin B12, iron, and magnesium, potentially leading to deficiencies that can cause anemia, neurological symptoms, or cardiac arrhythmias. Additionally, calcium absorption may be affected, potentially impacting bone health with long-term use. Monitoring creatinine is important as there is a small association between chronic PPI use and chronic kidney disease 1. For patients with risk factors for osteoporosis, consider periodic bone density testing as well. If deficiencies are detected, supplementation may be necessary while continuing PPI therapy, or in some cases, reducing the PPI dose or switching to H2 blockers might be considered. Some key points to consider when monitoring patients on chronic PPI therapy include:
- Regularly checking magnesium, vitamin B12, iron studies, calcium, and creatinine levels
- Monitoring for signs of deficiency, such as anemia, neurological symptoms, or cardiac arrhythmias
- Considering periodic bone density testing for patients with risk factors for osteoporosis
- Adjusting PPI dose or switching to alternative therapies if deficiencies are detected 1.
From the Research
Labs to be Trended on Chronic PPI Therapy
The following labs should be trended on chronic PPI therapy:
- Complete blood count (CBC) parameters, including red blood cell (RBC) count, white blood cell (WBC) count, and hemoglobin concentrations 2
- Serum levels of selected micronutrients such as:
- Serum homocysteine levels, as a marker of vitamin B12 deficiency 6
Rationale for Trending these Labs
Chronic PPI therapy has been associated with potential adverse effects on nutrient absorption, including:
- Reduced iron absorption, leading to iron deficiency 3, 2, 4
- Impaired vitamin B12 absorption, potentially leading to deficiency 3, 5, 6, 4
- Altered magnesium levels 3, 5
- Changes in zinc and copper levels 2
- Elevated homocysteine levels, indicating potential vitamin B12 deficiency 6
Clinical Implications
Trending these labs can help identify potential adverse effects of chronic PPI therapy and guide clinical management, including: